Feasibility of a combined strategy of HPV vaccination and screening in Mexico: the FASTER-Tlalpan study experience

Figures & data

Table 1. Checklist of evaluated elements, FASTER-Tlalpan Study, Mexico City, Mexico.

Vaccination component:
1. Space for refrigerators for vaccine storage
2. Number of refrigerators
3. Availability of portable coolers suitable for maintaining a cold chain in the doctor’s office
4. Electric generators in case of power outages
Screening component:
1. Existing private space suitable for the collection of samples dedicated to the timely detection of cancer
2. Space for the sample collection shared with other service(s) -not dedicated solely to timely detection
3. Appropriate examination table with examination lamp
4. Private space for the delivery of results and counseling

Table 2. Sociodemographic and clinical characteristics of the women in the FASTER-Tlalpan Study, Mexico City, Mexico.

		All screened women n = 3,474	Accepted the vaccine n = 3,228 (93%)
Age (years)	Mean (SD)	36.2 (6.0)	36.2 (6.0)
		n	n (%)*
Age groups (years)	25–34	1,360	1,265 (93.0)
	35–45	2,114	1,963 (92.9)
Education	Primary and middle school	1,980	1,832 (92.5)
	High school	964	901 (93.5)
	University	526	491 (93.4)
Occupation	Housemaker	1,915	1,772 (92.5)
	Employed	1,359	1,270 (93.5)
	Student	60	55 (91.7)
	Professional	134	125 (93.3)
Marital status	Single	789	729 (92.4)
	Married/Civil union	2,439	2,264 (92.8)
	Divorced/Separated/Widow	236	225 (95.3)
Age of sexual debut	17 years or under	1,579	1,473 (93.3)
	≥18	1,895	1,755 (92.6)
Total number of sexual partners	1	1,089	1.012 (92.9)
	2–3	1,538	1,417 (92.1)
	4+	846	798 (94.3)
Parity	0	1,366	1,281 (93.8)
	1–3	1,858	1,724 (92.8)
	4+	250	223 (89.2)

*Due to missing data, percentages might not add up to 100.

Table 3. Key themes on HPV vaccine acceptability among Mexican women, FASTER-Tlalpan Study, Mexico City, Mexico.

Themes	Subthemes	Selected Quotes
Prevention and health self-care	Infections/HPV/Transmission	“It’s a method of prevention”
		“To improve my health”
		“To not have this Papilloma virus illness”
		“It’s to prevent the illness in case I had it”
		“Because one never knows the [kind of] person who was in someone’s life previously and to avoid infections”
		“HPV currently affects women and it is good to prevent it”
		“For protection in case of having [sexual] relations and catching it”
		“To protect myself from the illnesses out there”
		“A control for future risks”
	Cervical Cancer	“To prevent a type of cancer because of having two partners”
		“I know it is something very important and it can prevent cervical-uterine cancer”
		“To be better protected”
		“So that I can be well and not get sick”
		“The Mexican woman is at great risk”
Sexual behaviors	Partner’s sexual behaviors	“Because my husband has had various partners”
		“I have a husband and one never knows what will happen or how faithful he is”
	Woman’s sexual behaviors	“I’ve had many sexual partners”
		“If I have unprotected sex I will be protected”
		“For safety and because with my partner, we don’t use that sort of protection”
Medical history	Cancer	“Because I have family history of cervical-uterine cancer”
	HPV Infections	“I need it because I have the virus”
		“I’ve had other infections and it is painful”
		“I am diabetic, and I want to prevent infections”
	Genital warts	“I would have liked to because I don’t know if it prevents other infections and I have some warts that I would like to treat”
Fear	Cancer	“I am afraid to get cancer and it is happening much more”
		“I do not get checked very often”
	HPV	“To prevent and to not get sick, because I am terrified of HPV”
	The future of their children	“For my health because I have to care for my children”
Benefits of the vaccine	Cost-free	“Because it’s free”
		“To take advantage of the fact that it’s free because they are very expensive and for prevention
	Healing properties and immunity	“It’s an alternative to a cure for this illness”
		“Because it creates antibodies for us”

Table 4. Reasons for rejecting the HPV vaccine among Mexican women, FASTER-Tlalpan Study, Mexico City, Mexico.

Fear of adverse reactions- Fear of getting the vaccine while on other medications

“I feel that there could be a reaction in my body”

“I didn’t accept it because of the fear of a reaction because I take an anticonvulsant and [medication] for hypertension”

“I am taking a lot of medications because I have asthma”

Fear of the inoculation- Perception of the vaccines being unsafe- Lack of trust in the vaccine

“I’m afraid of injections, I don’t want it”

“I do not trust the vaccine I think it is not useful for protecting us”

“It scares me, and I don’t trust it, people say it’s bad”

Lack of information

“I don’t have all the information and I have my doubts”

“I don’t have enough information about the vaccine and I prefer to ask”

“I don’t have the information and I’ve heard negative things”

Risk perception

“Because I don’t need it anymore”

“It’s not necessary and I don’t know what reaction will happen”

“I am not at risk”

Lack of interest

“I am not interested in the vaccine”

“I don’t have time”

“For the moment, I do not wish to participate in the vaccination program”

Table 5. Reasons that other women might reject vaccination, FASTER-Tlalpan Study, Mexico City, Mexico.

Lack of information/ignorance/beliefs/customs/religion

“Lack of information and ignorance, and habits and beliefs”

“Her religion doesn’t allow her [to get the vaccine], doesn’t permit it. Ignorance”

“All the taboos and what they say, that [the vaccine] affects and accelerates the cancer virus”

“Ignorance and the lack of knowledge of what it’s for or how it helps [HPV vaccine]”

“Because of ignorance and that it’s not just injectable water or the actual virus to cause illness”

“Because of their idiosyncrasies, or because of ignorance or lack of information”

“It’s ignorance because they think it’s going to give them HPV”

Partner attitudes/permission

“Because they allow themselves to be manipulated by their husband”

“Fear of the vaccine and of the thought of having to ask their husband for permission”

“Repressed by the husbands, unfortunately”

“Sometimes because their husbands are jealous and they [the women] don’t want their partners doing something to them”

Disinterest, laziness, lack of time

“Laziness, that they don’t care about their health”

“They leave it until the last minute, they don’t give it time, they don’t take care of themselves”

“To not come using the excuse that they don’t have time or because they have to take care of the children”

Lack of trust in the vaccine

“Fear of being used as guinea pigs”

“Fear of knowing that they have the virus and because they think that the government is trying to kill people”

“Fear because they think they are getting the illness injected and that then they will get sick”

“They don’t trust that the vaccine has been well tested in people”

They do not perceive that they are at risk

“They don’t think they can get papilloma, they blindly trust their partner”

“Because of disinformation or because they think that nothing will happen to her”

“They think they are healthy, and they don’t need it or that they will never get HPV”

Shame

“Because of shame or they already got HPV and they don’t want to get vaccinated”

“They are ashamed, the lack of information and because if they go ahead and do it they might feel it is because they have been really gross or dirty”

“Shame, laziness, they finally come around when they are dying”

“The lack of culture and shame of not being able to ask because they don’t even know what HPV is”

Lack of selfcare

“That they are irresponsible, and they don’t love themselves”

“Because they don’t care about their bodies or they are not well informed about the benefits for themselves”

“They don’t take care of themselves and they don’t care about their health”

Fear of what others will think (social norms)

“They are scared about what others will say”

“They are scared, because others may think that because they are getting vaccinated, that it means they already have the illness”

They do not perceive a benefit in being vaccinated as adults

“Because they are older and the information is for girls”

“Because there is no point in doing this for adults” “They are too old to receive the vaccine”

“They say that vaccines are not for adults because they don’t need them”

Fear of adverse reactions

“Because of fear of a reaction that could even lead to death and ignorance blinds us”

“Fear of being allergic or having some kind of reaction”

“Distrust, there is no trust in vaccines because of adverse reactions”

Vaccine cost

“The cost”

“Ignorance and not having economic possibilities”

Fear of the needle stick (jab)

“Ignorance and the fear of the pain of the prick”

“Because of fear of the pain of the prick”

Table 6. Strategies proposed by women to achieve the acceptability of the vaccine, FASTER-Tlalpan Study, Mexico City, Mexico.

Theme	Subtheme	Selected quotes
Provide information	HPV Infection	“Give more information about the vaccine and HPV screening so that they know that if they don’t take care of themselves, they could get the illness”
		“Bad information, give them information that won’t frighten them”
		“Give more information of all the cases that have happened”
		“More information, more dissemination and to have HPV statistics”
	Vaccine (benefits and possible risks)	“Inform the right way, the pro and cons of the vaccine”
		“Give information in pamphlets, because they only know it’s for girls”
	HPV related cancer	“More information because they have erroneous ideas like that it [the vaccine] causes cancer”
	Prevention	“Inform them that it is a means of prevention”
	Innovations	“Inform them of the research and the problems they could have”
		“More research”
	For the partner	“Provide more talks, information for the partner”
Motivation and sensitization	Motivation for the woman	“Convince them through talks explaining the way to prevent, that they think about their children”
		“Tell them that it is important that they get the vaccine and that it is for the good of themselves and their families”
		“Motivate people so that they value their lives”
	For the partner	“Remove the myths or machista comments from the men who doubt the effectiveness of the vaccine”
		“Talks for the men because they don’t understand”
Improvements to the health sector	Community work	“Go out to do fieldwork”
		“Give more talks to the community”
		“More promotion, go to the houses to give information”
	Care improvements	“Better treatment because sometimes [health care professionals] shout at you”
		“Give good service’
		“Be more human”
		“Give better attention”
	Add to current infrastructure	“More places for screenings”
		“Have more places”
	Counseling	“Explain with clear language”
		“Explain well, so that there are no doubts”
		“Reassure them and don’t give them alarming information that paralyzes them so that they can continue the treatment”
		“Transmit trust”
		“Dialogue is important to give the adequate information”
	Universal HPV vaccination	“Propose that the vaccine is obligatory”
		“Make it obligatory if not then their husbands won’t allow them to come”

Table 7. Potential barriers to HPV vaccination from a health-care professional perspective, FASTER-Tlalpan Study, Mexico City, Mexico. (N = 24).

Categorized barrier	Number of times barrier listed*
“Lack of information”	16
“They believe that the is not good/that it harms”	12
“Fear of the vaccine/distrust”	12
“There are many myths about the vaccine”	10
“They believe it sterilizes them”	6
“Because of the bad information transmitted through mass communication like the television”	6
“They fear the secondary reactions”	4
“They don’t believe in the vaccine”	4
“Because their husbands don’t let them (they are not given permission to make decisions)”	4
“Being unaware of the benefits/ignorance”	4
“Because of ways and customs”	2
“They believe that the vaccine kills”	1
“They believe that it can cause cancer”	1
“They doubt that it is authentic because it is free”	1
“They believe that HPV does not exist and that they don’t need the vaccine”	1
“They believe it will cause them to develop the papilloma virus”	1
“The cost of the vaccine through private means”	1
“Because they have to return to get a second dose of the vaccine (they might forget or don’t want the second dose)”	1

*All health-care professionals listened to more than one barrier.